According to the facility’s license, the facility has a maximum capacity of four (4) clients, all of whom must be ambulatory. This facility does not feature a secured perimeter or delayed egress doors.

LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility had large cob webs in the client bedroom. Bedroom #1's window screen was torn and the hallway bathroom tub was peeling and rusted with sharp edges. The trash can in the kitchen does not have a lid. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. All clients have a towel but only one towel, there was no supply of towels. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility does not encourage activities to include games or puzzles, only exercising and television. Hot water temperature at taps accessible to clients was compliant and measured at 111 F. A client is a diabetic that uses syringes, the syringes are being thrown away in the regular trash bin instead of properly disposed.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present. The food observed being served consisted of frozen foods, canned goods, hot dogs, and bologna. The staff cook a nutritious meal once a week. The client with diabetes had a physician's report that indicated a modified diet-low glycemic diet. However, the client is being served the same as the other clients. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. However, the tool shed in the backyard was accessible. Medications were labeled, as required, and stored in locked areas. Continued on an LIC 809C.

Required licensing postings were observed in visible areas of the facility. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files did not contain required documents for either staff or clients. Also, staff did not have required training. Confidential records were stored in locked areas. Licensee presented proof of current/active business liability insurance. LPA Requested a copy of current surety bond.

Deficiencies were observed and cited during today's annual inspection. In addition, Technical Violations and Technical Assistance was also provided. An exit interview was conducted with Staff, Myrna Rambayon, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.